Medical History (Anamnesis) Form:
Sexual History
_Current/Past sexual partners
a_Are you currently sexually active? Yes [ ] No [ ]
b_If no: Have you ever been sexually active? Yes [ ] No [ ]
c_What age did you start having sex? yeas old
d_In recent months, how many sex partners have you had? partners
e_In recent months, how many sex partners have been casual? partners
f_Are your sex partners? Men [ ], Women [ ], or Both [ ]?
_Current/Past sex practices
What kind of sexual contact do you usually engage in? Vaginal [ ] Oral [ ] Anal [ ]
_Current/Past contraception methods use
Aside from preventing pregnancy, some —but not all— methods of contraception can also prevent transmission of sexually transmitted infections (STIs).
Do you use any contraceptive methods or practice any form of birth control? Yes [ ] No [ ]
If no: why not?
If yes: Which method of contraception do you use and with what frequency?
a_Condoms [ ]
b_Pills [ ]
c_Morning-After Pills [ ]
d_Copper IUD [ ]
e_Hormonal IUD Kyleena [ ] Liletta [ ] Mirena [ ] Skyla [ ]